school dropout and rapid, repeated adolescent pregnancies (Linares et al., 1991). This is not a minor problem. According to one national study, 7.6 percent of children repeat kindergarten or first grade (Byrd and Weitzman, 1994). Children who are unable to achieve mastery on standard measures of school achievement also are at risk for delinquent and antisocial behavior (Yoshikawa, 1995), and children with early reading difficulties have increased rates of conduct problems up to the age of 16 (Fergusson et al., 1997).

Increased Burden on the Child Welfare System

The nation’s child welfare system also is greatly affected by the high prevalence of and disability associated with M/SU illnesses. Foremost, children who are reported to and investigated by the child welfare system for maltreatment typically have experienced a number of known risk factors for the development of emotional and behavioral problems, including abuse, neglect, poverty, parental substance-use problems and illnesses, and domestic violence. As a result, almost half (47.9 percent) of a nationally representative, random sample of children aged 2–14 who were investigated by child welfare services in 1999–2000 had a clinically significant need for mental health care (Burns et al., 2004).

In addition, the U.S. Government Accountability Office (GAO) has found that, because of limitations on insurance coverage, some families resort to placing their children (most often adolescents with severe mental illness) in the child welfare system even though the family is not neglectful or abusive of the child. Because the child welfare system often is able to secure mental health services otherwise unavailable to them, parents use the system for this purpose even though they are placing their children in systems not designed to care for children who have not been abused or neglected (GAO, 2003). Doing so sometimes requires parents to give up legal custody of their children and place them in an out-of-home residential or foster care setting (Giliberti and Schulzinger, 2000). In Virginia, for example, a 2004 study of the use of the state’s foster care program for mental health services found that 2,008 children in foster care as of June 1, 2004—approximately 1 of every 4 children in the system at that time—were there either because their parents wanted them to have mental health care not fully covered by their insurance or because the family did not have access to any insurance (Jenkins, 2004).

Finally, the stresses involved with child protective services investigation and judicial decision making, and for those who are placed in foster care the stress of removal from home, also constitute risk factors for maladaptive outcomes, including emotional, social, behavioral, and psychiatric problems warranting mental health treatment (Landsverk, 2005).

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